System And Technique For Accessing Extra Articular Lesions Or Abnormalities Or Intra Osseous Lesions Or Bone Marrow Lesions

ABSTRACT

A technique for accessing extra articular lesions or abnormalities or intra osseous lesions or abnormalities or bone marrow lesions or all has the step of positioning the localizing pinning member onto cartilage or subchondral bone to define a virtual pathway through the cartilage or subchondral bone towards or into or through the lesion or abnormality or a desired target to create the virtual pathway utilizing an intra articular localizing pinning member to determine a location of the lesion or abnormality wherein the utilization of the localizing pinning member includes the step to locate or stabilize or both and thereafter using the virtual pathway to create an entry access.

RELATED APPLICATIONS

This application is a continuation of co-pending U.S. application Ser.No. 15/889,883 filed on Feb. 6, 2018 entitled, “System And Technique ForAccessing Extra Articular Lesions Or Abnormalities Or Intra OsseousLesions Or Bone Marrow Lesions”, which is a division of co-pending U.S.application Ser. No. 15/265,178 filed on Sep. 14, 2016 entitled, “SystemAnd Technique For Accessing Extra Articular Lesions Or Abnormalities OrIntra Osseous Lesions Or Bone Marrow Lesions”, which is a continuationof U.S. application Ser. No. 15/080,947 filed on Mar. 25, 2016 entitled,“System And Technique For Accessing Extra Articular Lesions OrAbnormalities Or Intra Osseous Lesions Or Bone Marrow Lesions” which isa continuation-in-part of co-pending U.S. application Ser. No.15/080,980 filed on Mar. 25, 2016 entitled, “System And Technique ForAccessing Extra Articular Lesions Or Abnormalities Or Intra OsseousLesions Or Bone Marrow Lesions”, which claims priority from co-pendingprovisional application 62/297,478 filed on Feb. 19, 2016 entitled,“System And Technique For Accessing Extra Articular Lesions OrAbnormalities Or Intra Osseous Lesions Or Bone Marrow Lesions”.

FIELD OF THE INVENTION

The present invention relates to the field of addressing lesions of bonemarrow. A system and technique for accessing extra articular lesions orabnormalities or intra osseous lesions or bone marrow lesions is taught.

BACKGROUND OF THE INVENTION

Surgical procedures to repair bone defects such as lesions orabnormalities typically involve scooping out the damaged tissuematerial. One such procedure is called curettage. In these procedures,the bone is removed or opened to provide access to the lesion orcancerous tumor. This effectively weakens the bone structure because notonly has the damaged tissue been removed, but also some of the loadbearing solid bone structure. This is particularly problematic in thespine, the knees and the shoulder and articulating joints.

Ideally the surgeon would prefer to attack the problematic tissuewithout damaging the surrounding load bearing bone tissue. This isparticularly difficult, however, because the damaged tissue material tobe removed is hidden behind the joint. The current state of the art doesnot allow for accessing as well as addressing lesions of bone distant tothe entry point of the localizing site.

The presently available systems and techniques do not adequately addressthis concern. The present invention described below provides an improvedtechnique to remove the lesion, tumor or other abnormality withoutdamaging the outer joint bone structure, and the surrounding cartilage,and soft tissue. This enables the healing and functionality of therepaired joint to be faster and far less painful.

Definitions

Bone cement: The bone cement PMMA (polymethylmethyacrylate) starts outas a liquid and hardens over time. It can be put into a hole in the bonein liquid form. As PMMA hardens, it gives off a lot of heat. The heathelps kill any remaining tumor cells. This allows PMMA to be usedwithout cryosurgery for some types of bone tumors.

Bone Lesions: Various disorders can damage bones and result in bonelesions. Symptoms include bone pain or tenderness, and the injury canonly be seen using special imaging tests. Bone lesions are abnormalareas of bone typically identified using an X-ray or MRI. Lucent bonelesions are caused by rapidly progressing bone injuries. Scleroticlesions are bone injuries that develop more slowly, which allows thebone to attempt to wall off the damaged bone tissue. Bone lesionstypically have cancerous and non-cancerous causes.

Bone Marrow Lesions: (BMLs), common osteoarthritis-related magneticresonance imaging findings, are associated with osteoarthritisprogression and pain.

Curettage: In this procedure, the doctor scoops out the tumor from thebone without removing a section of the bone. This leaves a hole in thebone. In some cases, after most of the tumor has been removed, thesurgeon will treat the nearby bone tissue to kill any remaining tumorcells. This can be done with cryosurgery or by using bone cement.

Cryosurgery: For this treatment, liquid nitrogen is poured into the holethat is left in the bone after the tumor was removed. This extremelycold material kills tumor cells by freezing them. This treatment is alsocalled cryotherapy. After cryosurgery, the hole in the bone can befilled by bone grafts or by bone cement.

Osteoarthritis: is the most common form of arthritis, affecting millionsof people worldwide. It occurs when the protective cartilage on the endsof your bones wears down over time.

Osteochondritis dissecans: (OCD or OD) is a joint disorder in whichcracks form in the articular cartilage and the underlying subchondralbone. OCD usually causes pain and swelling of the affected joint whichcatches and locks during movement. OCD is caused by blood deprivation inthe subchondral bone. This loss of blood flow causes the subchondralbone to die in a process called avascular necrosis. The bone is thenreabsorbed by the body, leaving the articular cartilage it supportedprone to damage. The result is fragmentation (dissection) of bothcartilage and bone, and the free movement of these bone and cartilagefragments within the joint space, causing pain and further damage. OCDcan be difficult to diagnose because these symptoms are found with otherdiseases. However, the disease can be confirmed by X-rays, computedtomography (CT) or magnetic resonance imaging (MRI) scans.

Subchondral bone: bone located beneath or below the cartilage.

SUMMARY OF THE INVENTION

A system for accessing extra articular lesions or abnormalities or intraosseous lesions or abnormalities or bone marrow lesions or all has anintra articular localizing pinning member to determine a location of thelesion or abnormality. The utilization of the localizing pinning memberincludes positioning the localizing pinning member onto cartilage orsubchondral bone to define a virtual pathway extending through thelesion or abnormality to locate or stabilize or both prior to creating afirst entry access. The localizing pinning member never enters the bonylesion or abnormality but creates the virtual pathway penetrating atleast into or through the lesion or abnormality when set by holding thelocalizing pinning member positioned establishing a desired depth of atarget location along the virtual pathway. The system further has aguide component attachable to an exposed portion of the localizingpinning member at a predetermined position on a shank of the localizingpinning member. Manipulating the guide component about the localizingpinning member establishes the desired target location for the creationof the first entry access based on the relevant anatomy.

The guide component is adjustably movable to be set or fixed at thedesired first entry access point. The first entry access point can bemoved so a track extending from the first entry access point isadjustably aligned to intersect the virtual pathway at the desiredtarget location or adjusted therefrom by a fixed distance on the virtualpathway.

The system further has an adjustably movable guide having an opening forpassing a drill, a pin or a punch, the opening being translatable aboutthe guide component to form the first entry access to a desired depthwithin or in the proximity of the lesion or abnormality.

The guide component has a first arm for attachment to the localizingpinning member and a second arm for guiding a drill, a punch or a pin,the second arm being movably attached to the first arm. The second armhas an arcuate portion extending to a straight portion, the second armbeing coupled to and selectively movable relative to the first arm alongthe straight portion of the second arm. The straight portion of thesecond arm has a calibrated scale extending along at least a portion ofa length of the straight portion. A movement of the second arm relativeto the first arm along the straight portion of the second armcorrespondingly adjusts the first entry access location.

The first arm has a coupling end for attachment to the straight portionof the second arm. The straight portion of the second arm and thecoupling end of the first arm includes a distance adjustment mechanismto linearly move the second arm relative to the first arm. The distanceadjustment mechanism can be one of a screw, a gear, a ratchet, a wheel,a dial or a clip mechanism that moves the second arm to a desiredadjusted distance along the virtual pathway relative to an intersectionpoint of a track of a drill, punch or pin and the virtual pathway.

The first arm can be made disposable or non-disposable. The first arm ispreferably detachable for interchangeable arms having different tips,the tip being fixed, movable, annular, open, having a cross hair fortargeting or having points, flats or a guide sleeve.

The first arm is detachably coupled to the second arm. The second armcan be made of metal.

The system provides for a technique for accessing extra articularlesions or abnormalities or intra osseous lesions or abnormalities orbone marrow lesions or all. The technique has an intra articularlocalizing pinning member to determine a location of the lesion orabnormality, positioning the localizing pinning member onto cartilage orsubchondral bone to define a virtual pathway through the cartilage orsubchondral bone towards or into or through the lesion or abnormality ora desired target to create the virtual pathway wherein the surgeonselects a desired depth along the virtual pathway to establish thedesired target securing an adjustable guide component to an exposedportion of the localizing pinning member at an appropriate position on ashank of the localizing pinning member manipulating the guide componentwhile stabilizing the localizing pinning member to establish a desiredlocation for an entry access based on the relevant anatomy, theadjustable guide component is set or fixed at the entry access point,the adjustable guide component being movably adjustable to set or fix atrack of the entry access to intersect the virtual pathway at apreselected position. The technique further has a step of utilizing thefixed or set adjustable guide component to pass a drill, a pin or apunch at the entry access to a desired depth within or in the proximityof the lesion or abnormality, wherein the entry access alignment isdirected by the position of the localizing pinning member and theadjustable guide component, wherein straight lines, one line extendingalong a track of the localizing pinning member defining the virtualpathway and one line extending along a track of the drill, pin or punchforming the entry access intersect.

The one line extending along the track of the drill pin or punch can beadjustable parallel to the line by a predetermined distance (d) by theadjustable guide component to the track of the drill intersects thevirtual pathway at a location offset by the distance (d). The virtualpathway extends coincident with the localized pinning member through thedesired target and the entry access has an end at least in proximity to,in or through the lesion or abnormality wherein the desired target islocated short of the one line extending along the track of the firstaccess entry, beyond or an intersection.

The technique further has the step of utilizing the access entry to doone or more of the following steps: a) delivering a substance ormaterial to the proximity or location of the lesion or abnormality; b)modifying the lesion or abnormality; and c) introducing devices tomodify or visualize the lesion or abnormality. The technique of claim 23further comprises the step of securing a guide component to an exposedportion of the localizing pinning member at a predetermined position ona shank of the localizing pinning member manipulating the guidecomponent about the localizing pinning member to establish a desiredlocation for the creation of one or more entry access points based onthe relevant anatomy, and placing one or more pins or anchors throughthe cartilage and subchondral bone or through the subchondral bone, andfilling the lesion cavity with bone cement or other fixing materialpassed through one of said entry access to structurally support the pinsto repair the bone.

The lesion or abnormality is a tumor or an infection in affected tissue.The surgeon treating a tumor or infection removes some or all of theaffected tissue and further introduces stabilizing material. Thestabilizing material can include bone substitutes, bone cements,antibiotics, chemotherapy medication, stem cells, or any combinationsthereof.

BRIEF DESCRIPTION OF THE DRAWINGS

The invention will be described by way of example and with reference tothe accompanying drawings in which:

FIG. 1 shows a plan or frontal view of a relatively normal joint withthe bone marrow lesion from osteochondritis dissecans with the femurabove and the tibia below.

FIG. 2 shows the normal joint of FIG. 1 with the system of the presentinvention.

FIG. 3 demonstrates the normal joint with the first entry access andsecond entry access formed and the system device removed.

FIG. 3A is a plan view of an exemplary syringe filled with a bone puttyor similar material for injection through the second entry access.

FIG. 3B is an exemplary camera or imaging scoping device for visualizingthe lesion through the second entry access.

FIG. 3C is an example of an expandable reamer for cleaning the lesionmaterial during repair through the second entry access.

FIG. 4 demonstrates the guide system of the first embodiment of thepresent invention.

FIG. 5 is a second view of the joint of FIG. 1 showing an additionalentry access with the guide system of the first embodiment in place.

FIG. 6 shows the second view with the guide system of the firstembodiment removed.

FIG. 7 shows a camera in the second entry access.

FIG. 8 is an example of a prior art lesion fixation.

FIG. 9 shows a bone lesion.

FIGS. 9A, 9B and 9C show diagrammatically how the lesion can beseparated exposing the bone marrow.

FIG. 10 is a joint showing fixation anchors or pins pre-set through thesubchondral bone and cartilage with the second access extending towardthe end of the pins.

FIG. 11 shows how a bone cement can be injected with a filled syringeinto the lesion or abnormality cavity to encapsulate the pins or boneanchors.

FIG. 12 shows the repair structurally cemented and fully supportedlesion or abnormality repair.

FIG. 13 shows a second embodiment of the invention w herein a virtualpathway is used when positioning the localizing pinning member whichdoes not penetrate through subchondral bone or the cartilage asillustrated, but rather is located on the cartilage.

FIG. 14 shows the created second entry access to the lesion without aphysical access through the subchondral bone or cartilage whenperforming the method of the second embodiment.

FIG. 15 is a plan view of the guide system of the second embodiment.

FIG. 16 is a second view of the joint of FIG. 15 showing an additionalentry access with the guide system of the second embodiment in place.

FIG. 17 shows the second view with the guide system of the secondembodiment removed.

FIG. 18 shows a camera in the second entry access.

FIG. 19 is a use of either guide component wherein the localizing piningmember is moved to the second access entry to create additional accessentry.

FIG. 20 demonstrates the guide system of the third embodiment of theinvention wherein the guide component second arm is adjustably movablerelative to the first arm, as shown the first arm has a virtuallocalizing pin of the second embodiment.

FIG. 20A demonstrates an alternative version of the third embodimentwherein the first arm has an adjustable localizing pion member of thefirst embodiment.

FIG. 20B shows the guide system of the third embodiment wherein thesecond arm is shown moved a selected distance (d) relative to the firstarm wherein this adjustment moves the intersect location Lpt by theselected distance (d) thereby shift the first entry access parallel tothe initial setting per-translated to allow a redirected shifted Lptintersect.

FIG. 21 is a perspective view of the third embodiment with analternative guide component showing a syringe positioned to fill aprepared lesion.

FIG. 22 is an enlarged view of the movable guide of the thirdembodiment.

FIG. 23 is a second perspective view taken from FIG. 21 without thesyringe.

FIG. 24 is another perspective view of the third embodiment.

FIG. 25 shows a syringe for passing material through a cannulated sleevein the entry access, a drill is shown in the fore view.

FIG. 26 shows a portion of the third embodiment guide system and thedrill extending through the guide sleeve.

FIG. 27 shows a virtual localizing pin configured as a flat oval tipwith a centered target cross-hair feature.

DETAILED DESCRIPTION OF THE INVENTION

With reference to FIGS. 1-7, a first embodiment of the present inventionis illustrated. The first embodiment of the present invention providesfor a pinning member access 11, which is the first entry access, to becreated through the cartilage 5 and subchondral bone 7 using a guidecomponent 21 which further enables a localizing pinning member 30 topenetrate into the first entry access 11 and by utilizing the guidecomponent 21 allows for a precise location for a second entry access 12location to be created. The guide component 21 consists of first arm 22and second arm 24 including the straight portion 24A.

With reference to FIGS. 10-12, pins or anchoring devices 90 can beinserted through cartilage 5 and subchondral bone 7 into a lesion 10 orabnormity and the creation of a second entry access 12 location providesa means through which the pins or anchors 90 can be structurallysupported by the addition of bone cement 62. A syringe 60 can be placedinto the second entry access 12 through which the bone cement 62 orother fixing agents can be syringed through the second entry accessportal 12 into the lesion 10 to encapsulate the bone screw 90, as shownin FIG. 11. In FIG. 12, the residual cement 62 that is packed into thecavity where the abnormality or lesion was and the second entry accessis filled as illustrated sealing the opening wherein the anchors 90 arefirmly secured. This structurally supporting cementing of the pins oranchors 90 works equally well with the second embodiment of the presentinvention wherein the entry access 12 is used to fill the lesion cavity10, 10A and seal the angled tunnel or track entry access 12 to supportthe pins or anchors 90.

With reference to FIGS. 13-18, the second embodiment of the invention isillustrated. This second embodiment is very similar to the firstembodiment. However, the localizing pinning member 30 creates a virtualpathway 11V through the cartilage 5 and subchondral bone 7 withoutrequiring a pinning member 30 entry access 11 whereby an entry access 12can be created that intersects a line L₁ projected along the virtualpathway 11V from an end of the localizing pinning member 30 in such away that the entry access L₂ when projected along a track will intersectat a target location along the virtual pathway 11V. In this embodiment,as will be discussed later, the subchondral bone and cartilage need notbe penetrated and no pinning member entry access opening is created.However, the virtual pathway 11V is created projecting to a lesionallowing the surgeon to precisely direct and create one or more than oneentry access portals or openings 12, 14 using the guide component 21 ofthe present invention.

The present invention addresses lesions 10 of bone, as shown in FIG. 1,which may or may not be visualized arthroscopically. This could be insituations where the patient has intact articular cartilage 5, such asthe situation with osteochondritis dissecans. The surgeon can tell wherethe lesion 10 is by probing. There can be situations dealing withosteoarthritis or other lesions of the bone marrow where the subchondralbone 7 is intact. In either case, the surgeon wants to be able to locatewhere the lesion 10 of the bone is that can't be visualized, it isessentially extra articular, it is within the bone. This could be termeda bone marrow lesion, but in this technique, the surgeon uses intraarticular techniques to access the lesion.

The current art on this is very limited because generally it would beutilizing fluoroscopy or other means to vaguely localize where thatlesion might be. Sometimes the lesion can't even be seen on fluoro. Onemay argue that a pin can be placed in through it, but there are nolocalizing techniques other than fluoro and imaging which havesignificant limitations.

In the first embodiment of the present invention, as shown in FIG. 2,the provided device or system 20 of the present invention allows thesurgeon to actually put a pinning member 30 into the lesion 10 througharticular cartilage 5, or in a situation of the osteochondritisdissecans lesion, the surgeon can place the pinning member 30 throughthe subchondral bone 7 to address a bone marrow lesion 10. The surgeonapplies a guide component 21 to that localizing pinning member 30. Theguide component 21 has a movable guide 40 forming a system that allowsfor extra articular access to the end or point of the localizing pinningmember 30 which is something that is not visualized, but rather issomething within that bone marrow lesion 10 or within the bone at apoint 10A distal from the intra articular visualized entry point 11A andaccess to it occurs from outside the joint 2. The surgeon could actuallyaccess it from even inside the joint 2, but coming from a differentpoint or direction. And now by accessing the lesion 10 and removing thedamaged tissue, the surgeon can introduce substances into it, such asbone mineral grafting, calcium phosphate, etc. or you can even put acamera system 70, as shown in FIG. 3B, through the second entry accesstrack or portal 12 that was created to look at or modify the lesion 10by putting different types of reamers 80, shown in FIG. 3C, into it andselected substances using a syringe 60 filled with a material 62 such asputty or bone allograft or bone cement, as shown in FIG. 3A. Then onecan, after that has been done, put fixation pins 90 additionally into itfrom the intra articular utilizing the initial pinning member 30 access11, one can put pins and fixation devices 90 around it to help furtherfix the lesion, as shown in FIG. 3.

The limitation of the prior art techniques is that they allow for noprecise localization of lesions which cannot be seen. It may be arguedthat when one uses the prior art guide systems, the problem is thatthese create straight tracks. The prior art in line devices don't createangled tunnels, this inventive technique requires an angled tunnel to becreated because the surgeon wants the extra articular point of entry tobe somewhere remote from the pinning member 30 entry point 11A which isthe intra articular localizing point 11A. The best way to do that is tocreate an angled tunnel or an angled track. If using the standard priorart in-line guides, with its exit point at the intra articular pointcoming in from outside in, one does not create an appropriate track andcan actually violate that subchondral bone and the lesion. Furthermore,this does not provide an appropriate methodology for introducingsubstances in a sophisticated manner or in a precise manner. The presentinvention is a complete and different approach to it and introduces andprovides an entirely new system of devices and instruments to be usedfor these purposes. Limitations of the prior art as mentioned before isthere are no methodologies for addressing and accessing lesions onecannot see when one wants to visualize or repair remote from the initialentry localizing point. That is a big difference.

The present invention allows for precise localization of a lesion 10 anda way to access it while minimizing load bearing bone structure damagecaused by the surgical repair by essentially leveraging the inventor'sangled osteal tunnel concept of creating blind tunnels. In the firstembodiment, the surgeon is now able to drill a hole 11 into subchondralbone 7 of the femur 6 and from another angled entry point create anaccess track or portal 12 so the tip of that pinning member 30 and thedrill 50 extend along intersecting lines L₁ and L₂ so that the location10A is triangulated. This allows for precise localization of the lesion10 and access to it.

One example where this is most useful is to access the lesion 10 fromwithin the joint 2 such as the knee joint 2. This is calledintra-articular. The surgeon can drill a pinning member 30 from withinthe joint 2 into the bone even going through intact cartilage itnecessary. Then, from coming outside of the joint 2 with another drill50, he or she can then articulate to a blind spot or point 10A withinbone knowing it is accurate based on the precision of the guide system20 instruments. Often times, the lesion 10 being addressed maybe acystic lesion. The surgeon can then introduce other reamers 80 into thissecond access portal 12, the reamer 80 is configured to expand at tip 82once it gets to that desired lesion spot to clean this out. The removedlesion tissue forms a cavity which can then be filled with bone graftingmaterial substance 62 through a cannula 61 that came in from outside ofthe joint 2. This technique uniquely allows for blind targeting a pointor location 10A within bone. The invention in an earlier angled ostealtunneling technique, was for retrieving sutures. In this technique, thesurgeon is using the angled tunnels as portals 12, 14 for deliveringmaterial 62 to that spot. Additionally, he can also place a camera 72through one of the portals 14, see FIG. 7, which will then allow for himto directly visualize what is taking place within the lesion 10 usingone portal 14 for the camera 72 and another portal 12 for instruments.As shown, the camera 72 is connected by a flexible cable or tube 71 to adisplay monitor 78 for real time viewing.

One of the best examples of utilization of this technique is in the caseof osteochondritis dissecans. This is a serious lesion in children andyoung adults where the cartilage 5 can be intact within the joint 2, butthe bone 7 behind it essentially cystic or a vascular. The surgeon knowswhere the lesion 10 is from looking inside the joint 2, but he can'taccess the dead bone without violating the cartilage 5. Hence, with thisinventive technique, he simply drills up in through the intact cartilageto help stabilize it using the pinning member 30. Then coming fromoutside the joint 2 he can address the diseased bone, clean it out andput material 62 using the second entry access portal 12. He can then,from inside the joint 2, further stabilize the lesion 10.

There are a number of key points the inventor would like to emphasizeregarding the present invention. First, the access to a bony lesion 10from within a joint (intra-articular) or from outside the joint (extraarticular) is greatly enhanced. The ability to use the tunnel portaltracks 12, 14 either for retrieval or for delivery of materials 62 isachieved. The ability to use the tracks 12, 14 to place cameras 72 andworking instruments 80 to look inside of the bony lesions 10 isaccomplished. The precise targeting of bony lesions 10 blindly using atechnique of triangulation with the guide system 20 instruments ordevices of the present system is available.

FIG. 1 shows a relatively normal joint 2 with the bone marrow lesion 10from osteochondritis dissecans, as shown the joint 2 has the femur 6above and the tibia 4 below. The figure outlines the articular cartilage5 and right behind the cartilage is subchondral bone 7. Also drawn isthe capsule 3, anything outside the capsule 3 is what is called extraarticular; inside the capsule 3 is called intra articular space 9. Thebone marrow lesion 10 which is hidden from view because it is behindthat cartilage 5. It may be behind subchondral bone 7 in a situationwhere you have arthritis and don't actually have that cartilage over it.The point is one can't see the lesion 10 behind what they are looking atfrom the scope.

FIG. 2 shows how this would be addressed. The surgeon would put apinning member 30 through the cartilage 5 and the subchondral bone 7 orjust the subchondral bone 7 if there was no cartilage 5, so it actuallygoes into the bone marrow lesion 10. This pinning member 30 can go intoit or it can go all the way through the lesion 10. Then, utilizing theguide system 20, coming from outside in a generally extra articularapproach, but it may not be if it just comes in from a differentdirection to form a second or even more access portals 12, 14. In anyevent, these second and one or more additional portals 12, 14 do not gothrough the articular cartilage 5. The key is that the surgeon isaccessing this lesion 10 within the bone from a safe area that doesn'tdamage the joint 2. The access doesn't damage the other anatomicalstructures; that is why he has to have the variability of a range ofdepth and the variability of a range of angles combined with the abilityto rotate the guide component 21 around the axis of the pinning member30. One can't have a fixed point of entry because that can be dangerous.This adjustment capability allows the surgeon to access the lesion 10from a different location, generally an extra articular location, that'swhat's demonstrated how the guide 20 works on this example as shown inFIG. 2.

FIG. 3 demonstrates what is done when you have that track formed on anangled osteal tunnel access portal 12. Once that separate track 12 iscreated, the surgeon can enlarge the track 12 with reamers 80, can putdifferent types of reamers 80 in, which are small going in, then theyexpand once they get to the lesion 10, flip cutters, or other types thatcan be utilized in that situation. The surgeon can use the track oraccess portal 12, 14 to fill the cavity created when the lesion tissueis removed with different substances 62 including bone mineral matrices,stem cells, or can even put cameras 72 inside. As illustrated, a puttyfilled syringe 60, a camera system 70 or an expandable reamer 80 withtip end 82 can be used, as shown in FIGS. 3A, 3B and 3C respectively.Once filled in, these different substances can set, then the surgeon cango back into the joint 2 and can put multiple pins 90, and fixationdevices 90 which can now be better fixed because there is some substancewithin the lesion 10 cavity which to fix them to.

FIG. 4 demonstrates what the guide system 20 looks like. It demonstrateshow an intra articular guide pinning member 30 is placed, how the guidecomponent 21 then attaches to the pinning member 30 at an appropriatedepth. The guide component 21 has a swinging arcuate arm 24 that comesaround and allows the precise localization and alignment tip to tip eventhough one can't see what is essentially a blind tip 10A. This allowsaccess for things you can't see. Again, completely eclipses any type ofcurrent prior art using poor techniques such as fluoro, etc. forvisualization. With the present invention, the surgeon knows exactlywhere he is with precise localization for addressing the lesion in acompletely different way of practicing medicine.

As shown in FIG. 4, the guide system 20 has a guide component 21. Theguide component 21 has a straight first arm portion 22 that extends in astraight path to an end 22A for holding a pinning member 30. The end 22Ais transverse to the arm portion 22. As shown, the shank of the pinningmember 30 has marked gradations 33 that establish the distance to thetip or point 30A. The pinning member 30 can be a pin, a drill bit orpunch, by way of example. At the end 22A, a shank tightening nut 34 orfixation device is shown that, when tightened, holds the pinning member30 securely to the arm 22 thereby fixing the tip 30A location. At theopposite end 22B of the first or straight arm 22 is a second swing orarcuate arm 24. The second arm 24 is shown in a partial section viewshowing a slot 23 that allows a movable guide 40 to slide in the slot 23over a range of angles between at least 0 and 90 degrees relative to thetip of the pinning member 30, most typically between 30 and 60 degrees.Preferably, the movable guide 40 has a cannulated shaft, sleeve or tube42 with a tightening clamp 41 having a nut 43 that fixes the movableguide 40 onto the second arm 24 anywhere along the slotted opening orslot 23. As shown, a drill bit, a punch or a trocar 50 can be slippedthrough the movable guide 40 tube 42 to create the second access portalor track 12, 14. Preferably, when locating the desired location to formthe second or additional access portals, the tube 42 is moved relativeto the guide 21 to set the tube solidly against the tissue then thecomponents are tightened to fix the angle and the sleeve length. Thenthe drill 50 can be inserted to create the second or more access tracksor portals 12, 14. The shape of the guide component 21 allows the system20 to be pinned at one location and flipped to an opposite side of theknee joint while still pinned if desired to make additional or eventhird or more access portals or tracks as shown in FIG. 5. This featuremakes the procedure to create additional entry points remarkably easy.Once the two access portals 12, 14 are created, the use of a visualizingcamera system 70 as the surgeon uses other devices and instruments toremove or repair the lesion 10 is available so real time observation ofthe surgical repair is available which vastly improves the likelihood ofsuccessful lesion tissue removal and treatment. Once the lesion 10cavity is cleared, substances 62 can be added through the access portal.One such substance 62 is bone cement that can greatly improve screw orpin fixation.

Essentially the next aspect of this is taking bone marrow lesions 10with ocd and osteochondritis dissecans and when the surgeon is trying tofix these, generally the bone 7 behind it is poor so he is not gettingvery good fixation so the two additional elements are needed after oneutilizes the technique, either after or during utilization of thetechnique the surgeon can actually put screws in place, they can bemetal or they can be biocomposite. These fixation devices 90 actually gointo the lesion 10 then he can put the substance 62 around it, the groutor a bone cement which may include different types of bone cement,different types of putty 62, which might harden when set actually allowthe screw to be better fixed, alternatively he can put the bone cementsubstance 62 in the lesion cavity first, then screw directly through itwhich can again both of these provide better fixation than without anyof the bone substances 62. The cement is either put around once thescrews are placed or the screws 90 are placed through it. And these canbe screws or these can be darts or any variety of fixation devices 90.

FIG. 8 is the picture showing what an OCD lesion would look like intraarticular, you can see the cartilage wrap 5 coming off and thesubchondral bone 7 behind it. Often you can't see the bone behind it.This one is a lesion 10 that is more advanced and fixation pins 90 areplaced to stabilize the bone.

FIG. 9 is a picture with 3 photos 9A, 9B and 9C above it showing how alesion 10 has completely come off and that is what the bone 7 looksbehind it. There is more dead bone behind that we want to access soeither you could have a cartilage cap that was intact on it or you havethe exposed bone. That is why with the guide system 20 one can gothrough either cartilage 5 or intact bone 7 when it is exposed. Thatbone is called subchondral bone 7. Again, the surgeon wants to getbehind it and he can't see it, that's why he wants to pass the tip orend of the pinning member and that's the tip end that he wants to accessblindly from a different portal 12, 14. One can see on FIG. 9 that's thex-ray which shows what a lesion 10 like this might look like, and onecan try to pin that lesion or try to get behind it.

The FIG. 8 illustration of this is an actual photograph just shows howone currently can secure that lesion 10, stabilize with screws ordegradable pins 90, 92. The present invention technique is morepredicated upon actually a couple of different things. Number oneaddressing the tissue behind that bone and then more importantly, oncethat has been actually addressed that tissue, where bone marrow lesionhas been removed can be filled with substances such as cement, etc. Nowthe surgeon can fix into those substances which is another extension ofthis system because one of the things now that can be done because onehas created an appropriate bed behind that lesion you now have newtechniques of fixation which can actually fix into that bone whichcurrently cannot be done because there is no way of stressing thatfoundation absent this type of repair.

The second or the first entry access itself or the track created can beenlarged. It's important to note that the second entry access, althoughgenerally extra-articular, does not necessarily have to be so. Moreimportantly, this access track can be away from the cartilage andsubchondral bone so that it does not damage these structures. Thecurrent state of the art does not allow for addressing lesions of bonedistant to the entry point of the localizing site. It is also importantto restate that the present inventive technique allows for accessing oraccessing as well as addressing the lesion. Specifically, although thesurgeon can address bone lesions by removing damaged tissue, sometimeshe can choose to address them by simply adding structural materials orstem cells or both without removing any tissue.

An important feature of this technique is that fixation of the lesionutilizing stabilizing devices such as the initial localizing pin oradditional ones which can now either be drilled or punched through thelesion and then be filled with the grout material, such as concretebeing poured on rebar, or filling with the grout material before andthen the fixation device is placed through it, such as placing screwsthrough concrete once it has set. This introduces an entirely newmethodology of addressing these lesions which previously has not beeneffectively or precisely performed.

With reference to FIGS. 10-12, a normal joint with a lesion 10 is shownwhere the lesion has been prepared forming a cavity in the region 10 and10A. In this cavity, bone anchors, screws, or anchors or pins 90 can bepositioned as illustrated in FIG. 10. These pins and screws 90 enterinto the cavity location as shown in FIG. 10. With reference to FIG. 11,when a syringe 60 is positioned into the entry access 12, the syringefilled with bone cement 62 can be used to deliver bone cement or otheradhesive or bonding material into the cavity 10 or 10A of the lesion 10.When this occurs, the bone cement 62 encapsulates and surrounds theanchors 90 that have previously been positioned as illustrated in FIG.10. As the cement fills the cavity, the syringe 60 can be backed out andas illustrated in FIG. 10, the entire entry access portal 12 can befilled. This provides a secure structurally enhanced repair of the areawhere the lesion 10 or abnormality had existed, as illustrated in FIG.12. Alternatively, a bone repair mixture 62 can be inserted into thecavity via the entry access portal 12 and then the screws or pins 90 canbe positioned drilling into the cement 62. If the cement 62 is soft, itwill simply go into the cavity and will surround the screws or pins 90with the cement 62 which will harden later or alternatively if providedwith sufficient cutting flutes, can be threaded into the prepared areawith the cement 62 already hardened. Any of these methodologies arepossible with the benefit that the damaged knee will be strengthenedsubstantially by the introduction of the bone hardening cement 62 intothe cavity 10, 10A via the entry access 12.

With reference to FIGS. 13-18, a second embodiment of the invention isshown. The second embodiment uses a guide component 21 similar to theguide component 21 of the first embodiment. However, in this embodiment,the localizing pinning member 30 is short, shown truncated, having apoint or tip 30A that can rest onto the cartilage 5 above thesubchondral bone 7. In this location 11A, the tip 30A can be pinned ontothe cartilage 5 so that it is held there by the surgeon and the entryaccess portal 12 can be created using the movable guide 40. The movableguide 40 can then have a drill, punch or trocar 50 directed into thebone towards the lesion 10 to create an entry access portal 12. Asillustrated in FIG. 14, the entry access portal 12 is shown approachingthe region of the lesion 10 and is delivered to a desired targetlocation within the lesion. What is unique about the second embodimentmethod is, as shown in FIG. 14, there is no hole or first entry accesstunnel 11 created by the localizing pinning member 30 instead a virtualpathway 11V is created by the guide component 21. As shown in FIG. 15,the guide component 21 has the arcuate arm 24 with the movable guide 40that can be positioned anywhere along the angular approach of thearcuate arm portion 24. The straight arm portion 22 holds the localizedpinning member 30. The localized pinning member 30 may have gradations33 as previously discussed along the shank of the pinning member 30.However, the pinning member 30 has an end 30A that rests on top of thecartilage 5 and subchondral bone 7 such that a virtual pathway 11V alongline L₁ is created pointing into the lesion 10. If desired, when themovable guide 40 is positioned along the arcuate arm portion 24, asecond line L₂ is created. The intersection of lines L₁ and L₂ createsthe desired target location or point LPT as illustrated. The benefit ofthis component is that no cartilage or subchondral bone needs to be cutor drilled into using this device. As shown in FIG. 16, the entry accessportal 14 is already created using the virtual pathway 11V that wasfurther described with reference to FIG. 13. In FIG. 16, however, thedevice can be then pivoted in such a fashion that an additional accessportal 14 can be created on an opposite side of the joint asillustrated. Again, when pivoting the guide 21, the subchondral bone andcartilage are never penetrated through, however, all access portals willbe directed along the virtual pathway 11V of the localized pinningmember 30. With reference to FIG. 17, multiple entry access portals 12and 14 are illustrated. With reference to FIG. 18, a device 80, 81 isshown on one side with the device 70 with a camera viewing the area ofthe lesion 10 through the additional access portal 14. In this fashion,the device 80 can be used to probe into the cavity where the surgeonobserves what is happening using the camera 70.

With reference to FIG. 19, the guide component 21 can be repositionedsuch that the localized pinning member 30 is positioned in the entryaccess 12. When this occurs, the surgeon can locate an additionallocation for an entry access or an additional entry access 14 by simplypivoting the guide component 21 about the localized pinning member 30positioned in the access portal 12 in such a fashion that the movableguide 40 can then be positioned and directed such that an additionalentry access portal 14 can be drilled on the opposite side of the bone.In the embodiment of FIG. 19, a pin 90 is shown positioned in the areaof the lesion 10. This method of moving the localized pinning member 30to an entry access portal for making additional entry access portals canbe used with either the first embodiment of the invention or the secondembodiment of the invention.

With reference to FIGS. 20-27, the present invention is shown with athird embodiment having a guide component that is suitable for use withthe virtual pathway concept of the second embodiment as shown in FIGS.20, 21, 26 or the localizing pinning member 30 of the first embodimentas illustrated in FIGS. 20A and 20B. The guide component 21 has thefirst arm 22 for holding the localizing pinning member 30 detachablefrom the device. The first arm 22 is coupled to a coupling end 26. Thecoupling end 26 is configured to move along a straight portion 24A ofthe second arm 24. The straight portion 24A extends to the curvedarcuate portion of the second arm 24. As illustrated in FIGS. 20, 20Aand 20B the second arm 24 is shown having a slot 23 that allows themovable guide 40 to slide in the slot 23 over a range of angles. As inprevious embodiments, the second arm 24 is shown in a partial sectionview showing a slot 23 that allows a movable guide 40 to slide in theslot 23 over a range of angles between at least 0 and 90 degreesrelative to the tip of the pinning member 30, most typically between 30and 60 degrees. Preferably, the movable guide 40 has a cannulated shaft,sleeve or tube 42 with a tightening clamp 41 having a nut 43 that fixesthe movable guide 40 onto the second arm 24 anywhere along the slottedopening or slot 23. As shown, a drill bit, a punch or a trocar 50 can beslipped through the movable guide 40 tube 42 to create the second accessportal or track 12, 14. Preferably, when locating the desired locationto form the second or additional access portals, the tube 42 is movedrelative to the guide 21 to set the tube solidly against the tissue thenthe components are tightened to fix the angle and the sleeve length.Then the drill 50 can be inserted to create the second or more accesstracks or portals 12, 14. The shape of the guide component 21 allows thesystem 20 to be pinned at one location and flipped to an opposite sideof the knee joint while still pinned if desired to make additional oreven third or more access portals or tracks as shown in FIG. 5. Thisfeature makes the procedure to create additional entry points remarkablyeasy. Once the two access portals 12, 14 are created, the use of avisualizing camera system 70 as the surgeon uses other devices andinstruments to remove or repair the lesion 10 is available so real timeobservation of the surgical repair is available which vastly improvesthe likelihood of successful lesion tissue removal and treatment. Oncethe lesion 10 cavity is cleared, substances 62 can be added through theaccess portal. One such substance 62 is bone cement that can greatlyimprove screw or pin fixation.

What is clearly different from the first two embodiments is the straightportion 24A provides a way for the surgeon to precisely adjust the trackof the drill forming an entry access 14 without changing the angleestablished by the movable guide component 40. This is achieved bymoving the second arm 24 relative to the first arm 22 from an initialposition from d=0 to a shifted position by a second distance d=x bymoving the coupling end 26 of the first arm 22 along the straightportion 24A by precisely having the second arm 24 moved relative to thecoupling 26 and of the first arm 22. This shift by a preselecteddistance (x) correspondingly shifts the track of the entry accessexactly a distance (x). This means the surgeon can move the entry trackwithout altering the angle. The secondary adjustment enables the surgeonto select an optimal access to the region in or near the lesion orabnormality that is being treated. It is not uncommon for the optimalentry approach angle to provide a track that is not exactly ideal for atreatment. This added feature of adjusting an entry track by a preciseoffset distance allows the angulation to remain optimally fixed as thelocation is shifted by a pre-selected offset distance (d). This resultsin the initial entry access track is shifted to an offset track that isparallel to the original initial access track as the shift adjustmentbeing clearly shown in FIGS. 20A and 20B. In FIG. 20A, the initial trackL₂, shown in dashed lines, intersects line L at LPT and when the secondarm 24 is shifted a distance (d) relative to the coupling 26 and lockedin by a thumb screw 27, the access track line L₂ is shifted to LPT′ thesame distance (d). This capability to adjust angulation at the arcuateportion 24 and also shift to an offset distance at the straight portion24A affords the surgeon a convenient and very reliable way to createblind access openings for treating lesions and other abnormalities. Thisincludes the treatment of tumors and infections in addition to the otherproblems discussed. Specifically, with respect to tumors, the surgeoncan introduce stabilizing materials such as different types of bonesubstitutes as well as cement. It also allows him to deliver targetedablation agents and chemotherapy. With respect to bone infections, itcan also allow for delivery of bone agents and cement as well asantibiotics. These are both incredible indications that heretofore werenever really accessible so precisely being nearly impossible to targetindications.

A variation of the system for accessing extra articular lesions orabnormalities of the third embodiment is illustrated in FIGS. 21-26. Inthis variation, the guide component 21 is made in a simplified structurewhere the second arm 24 is made as a solid rod having a straight portion24A and an arcuate portion 24 formed as a single piece without a slot.As shown, the movable coupling 26 and the movable guide 40 are simplyslipped onto the guide component 21. The calibrated gradations 33A areshown extending all along the guide component 21 in both the straightportion 24A and the arcuate portion 24. The movable guide 40 has asleeve 42 detachably connected and the guide 40 has a locking button 48which, when depressed, allows movement of the guide 40 about the arcuatearm 24 and, when released, holds the guide 40 in a fixed position. Thelocking feature 48 can be constructed in a variety of alternatives suchas a thumb screw or its equivalent. Similarly, the coupling 26 has asimilar locking button 29 that when depressed releases so the second arm24 along the straight portion 24A can be adjusted as previouslydiscussed. As shown, the device of this embodiment has a handle 28 toprovide the surgeon a convenient way to hold the system 20 as he setshis access track and his offset to precisely pinpoint the track of anentry access. As noted, the device can be moved to create multiple entryaccess openings if so desired. At the end of the movable guide 40 is anaccess portal 47 provided to receive a syringe 60 or camera 72 or anyother tool that may be needed to pass into an entry access openingformed by a drill 50 or punch or tap, shown in FIG. 25.

As shown in FIG. 26, the drill 50 or punch or tap is guided through thesleeve 42 when set to create an access opening. One important aspect ofthe system is an axis of the localized pinning member 30 and an axis ofthe guide sleeve 42 in every embodiment shown lie in a single plane.This insures the virtual pathway L₁ and the access track L₂ whenextended will intersect. The surgeon, when creating the entry accessopening, can select the depth of the opening to be created short of thepoint of intersection, at the point of intersection or past and beyondit. This can be done by simply drilling to a predetermined distance, thesurgeon can mark on the drill 50 and when that mark is reached, he canknow exactly where an end of the access opening is, which in thisinvention can be called the desired target location.

The system 20 shows the localizing pinning member 30 as a pointedelongated pin 30, or a short virtual pin 30. As shown in FIG. 27, thepin 30 can be made as an oval or annular ring at the end of the firstarm 22. The annular ring preferably has a cross-hair centered in theopening creating a virtual target observable by the surgeon.Alternatively, the pinning member 30 can be cannulated to form an accessentry sleeve if so desired.

Variations in the present invention are possible in light of thedescription of it provided herein. While certain representativeembodiments and details have been shown for the purpose of illustratingthe subject invention, it will be apparent to those skilled in this artthat various changes and modifications can be made therein withoutdeparting from the scope of the subject invention. It is, therefore, tobe understood that changes can be made in the particular embodimentsdescribed which will be within the full intended scope of the inventionas defined by the following appended claims.

What is claimed is:
 1. A method of treating a compromised portion of abone structure, comprising: determining a reference location on anexterior surface of the bone structure defining a virtual axis extendingthrough a target location adjacent to or within the compromised portionof the bone structure; determining an offset distance along the virtualaxis from the reference location to the target location; determining anaccess axis extending through the bone structure at a location remotefrom the reference location and intersecting the target location,wherein the access axis extends through the virtual axis at a positiondefined by the offset distance; and forming, at least partially to thetarget location, an access passage along the access axis from theexterior surface of the bone structure using an access instrument,wherein said forming of the access passage includes mechanicallyconstraining the access instrument relative to the reference locationduring said forming of the access passage.
 2. The method of claim 1,wherein determining the offset distance includes imaging, prior to saidforming of the access passage, a mass of the bone structure to identifyinformation characterizing a distance between the target locationrelative and the reference location.
 3. The method of claim 1, wherein:said mechanically constraining the access instrument relative to thereference location includes engaging the access instrument with avirtual axis access apparatus that is adapted to maintaining the accessinstrument at a fixed distance relative to the reference location and ina fixed angular orientation relative to the virtual axis; forming theaccess passage includes arthroscopically viewing the exterior surface ofthe bone structure during said forming of the access passage and usingsaid arthroscopic viewing of the exterior surface of the bone structureto maintain a reference structure of the virtual axis access apparatusin contact with the exterior surface of the bone structure at thereference location thereof.
 4. The method of claim 1, wherein saiddetermining of the access axis includes determining an angularorientation of the access axis relative to the virtual axis.
 5. Themethod of claim 1, wherein: said forming the access axis is performedusing a virtual axis access apparatus; and said mechanicallyconstraining the access instrument relative to the reference locationincludes: engaging the access instrument with the virtual axis accessapparatus; engaging a reference structure of a virtual axis referenceapparatus with the reference location on the exterior surface of thebone structure; and using the virtual axis access apparatus to manuallymanipulate an orientation of the virtual axis reference apparatus suchthat the virtual axis and the access axis both extend through the targetlocation.
 6. The method of claim 5, wherein said mechanicallyconstraining the access instrument relative to the reference locationfurther includes: engaging the access instrument with an angularorientation adjuster of the virtual axis access apparatus jointlysetting the angular orientation adjuster and an offset distance adjustorof the virtual axis access apparatus such that a distance between thereference structure of the virtual axis access apparatus and a point atwhich the access axis as defined by the angular orientation adjusterintersects the virtual axis as defined by the reference structure of thevirtual axis access apparatus is the same as the offset distance.
 7. Themethod of claim 6, wherein the access axis extends through the virtualaxis at a position defined by the offset distance.
 8. The method ofclaim 6, wherein the virtual axis access apparatus that is adapted tomaintaining the access instrument at a fixed distance relative to thereference location and in a fixed angular orientation relative to thevirtual axis; forming the access passage includes arthroscopicallyviewing the exterior surface of the bone structure during said formingof the access passage and using said arthroscopic viewing of theexterior surface of the bone structure to maintain the referencestructure of the virtual axis access apparatus in contact with theexterior surface of the bone structure at the reference locationthereof.
 9. The method of claim 8, wherein: the bone structure includessubchondral bone and cartilage supported thereby; the reference locationon the exterior surface of the bone structure is at an exposed surfaceof the cartilage within an appendage articulation joint; said engagingthe reference structure of the virtual axis reference apparatus with thereference location on the exterior surface of the bone structureconsists of engaging the reference structure with the exposed surface ofthe cartilage; said forming the access passage includes arthroscopicallyviewing the exposed surface of the cartilage supported by thesubchondral bone during said forming of the access passage; and saidmechanically constraining the access instrument relative to thereference location includes using said arthroscopic viewing of theexposed surface of the cartilage to maintain engagement of the referencestructure of the virtual axis reference apparatus at the referencelocation.
 10. The method of claim 1, wherein: said forming the accessaxis is performed using a virtual axis access apparatus; saidmechanically constraining the access instrument relative to thereference location includes: engaging the access instrument with anangular orientation adjuster of the virtual axis access apparatus; andjointly setting the angular orientation adjuster and an offset distanceadjustor of the virtual axis access apparatus such that a distancebetween the reference structure of the virtual axis access apparatus anda point at which the access axis as defined by the angular orientationadjuster intersects the virtual axis as defined by the referencestructure of the virtual axis access apparatus is the same as the offsetdistance; and said forming the access passage includes manipulating anorientation of the virtual axis reference apparatus such that thevirtual axis and the access axis both extend through the target locationwhile maintaining a reference structure of the virtual axis referenceapparatus with the reference location on the exterior surface of thebone structure.
 11. The method of claim 10, wherein: the access axisextends coincidental with a longitudinal axis of a central passage ofthe angular orientation adjuster; and said mechanically constraining theaccess instrument relative to the reference location includes engaging aportion of the access instrument within the central passage of theangular orientation adjuster.
 12. The method of claim 10, wherein thevirtual axis access apparatus that is adapted to maintaining the accessinstrument at a fixed distance relative to the reference location and ina fixed angular orientation relative to the virtual axis; forming theaccess passage includes arthroscopically viewing the exterior surface ofthe bone structure during said forming of the access passage and usingsaid arthroscopic viewing of the exterior surface of the bone structureto maintain the reference structure of the virtual axis access apparatusin contact with the exterior surface of the bone structure at thereference location thereof.
 13. The method of claim 12, wherein: thebone structure includes subchondral bone and cartilage supportedthereby; the reference location on the exterior surface of the bonestructure is at an exposed surface of the cartilage within an appendagearticulation joint; said engaging the reference structure of the virtualaxis reference apparatus with the reference location on the exteriorsurface of the bone structure consists of engaging the referencestructure with the exposed surface of the cartilage; saidarthroscopically viewing the exterior surface of the bone structureincludes arthroscopically viewing the exposed surface of the cartilagesupported by the subchondral bone; and said mechanically constrainingthe access instrument relative to the reference location includes usingsaid arthroscopic viewing of the exposed surface of the cartilage tomaintain engagement of the reference structure of the virtual axisreference apparatus at the reference location.
 14. A method ofintra-articular referencing to treat a compromised portion of a bonestructure, comprising: imaging the bone structure to determine alocation of the compromised portion of the bone structure relative to anexterior surface of the bone structure within an appendage articulationjoint; determining, at least partially using information from said bonestructure imaging, at least one of a reference location on the exteriorsurface of the bone structure within the appendage articulation jointdefining a virtual axis extending through a target location adjacent toor within the compromised portion of the bone structure and an offsetdistance along the virtual axis from the reference location to thetarget location; determining an access axis extending through the bonestructure at a location outside of the appendage articulation joint andintersecting the target location, wherein the access axis extendsthrough the virtual axis at a position defined by the offset distance;and forming, at least partially to the target location, an accesspassage along the access axis from the exterior surface of the bonestructure at the location outside of the appendage articulation joint.15. The method of claim 14, wherein: the bone structure includessubchondral bone and cartilage supported thereby; said determining of atleast one of the reference location and the offset distance includesdetermining the reference location; the reference location structure isat an exposed surface of the cartilage within the appendage articulationjoint; said forming the access passage includes arthroscopically viewingthe exposed surface of the cartilage during said forming of the accesspassage using said arthroscopic viewing of the exposed surface of thecartilage to maintain extension of the virtual axis through the targetlocation during said forming.
 16. The method of claim 14, wherein saiddetermining of the offset distance includes using said bone structuremass imaging to visualize a distance between the target locationrelative and the reference location.
 17. The method of claim 14, whereinsaid determining of the access axis includes determining an angularorientation of the access axis relative to the virtual axis.
 18. Themethod of claim 14, wherein said forming the access passage includes:overlying a longitudinal axis of an access instrument onto the accessaxis; and mechanically constraining the access instrument relative tothe reference location during said forming of the access passage. 19.The method of claim 18, wherein: said forming the access passageincludes using a virtual axis reference apparatus; and said mechanicallyconstraining the access instrument relative to the reference locationincludes: engaging the access instrument with the virtual axis referenceapparatus; engaging a reference structure of the virtual axis referenceapparatus with the reference location on the exterior surface of thebone structure; and using the virtual axis reference apparatus tomanually manipulate an orientation of the virtual axis referenceapparatus such that the virtual axis and the access axis both extendthrough the target location.
 20. The method of claim 19, wherein saidmechanically constraining the access instrument relative to thereference location further includes: engaging a portion of the accessinstrument with an angular orientation adjuster of a virtual axis accessapparatus; and jointly setting the angular orientation adjuster and anoffset distance adjustor of the virtual axis access apparatus such thata distance between the reference structure of the virtual axis accessapparatus and a point at which the access axis as defined by the angularorientation adjuster intersects the virtual axis as defined by thereference structure of the virtual axis access apparatus is the same asthe offset distance.